a client who had an elective below the knee amputation reports pain in the foot that was amputated what is the best response by the nurse

ATI RN

Multi Dimensional Care | Final Exam

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

A. The pain will go away after the swelling decreases.
B. That is phantom limb pain.
C. Your foot has been amputated, so you are not having pain in that foot.
D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. What medication class can decrease tissue in inflammation but delays bone healing?

A. Opioids
B. Anticoagulants
C. Narcotics
D. Nonsteroidal anti-inflammatory drugs (NSAIDS)

Correct answer: D

Rationale:

3. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

A. The client is in a private room.
B. The client has a vase of fresh flowers on the table
C. The client has a dedicated vital signs machine
D. There is hand sanitizer by the door

Correct answer: B

Rationale:

4. What is not a potential complication of RA?

A. Paresthesia's
B. Fibromyalgia
C. Joint deformity
D. Dry eyes

Correct answer: A

Rationale:

5. What is a priority intervention when caring for a client in Buck’s traction?

A. Adjust the size of the traction weights PRN as needed
B. Discontinue the traction once the client has pain relief
C. Ensure the traction weights rest on the floor
D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.